How to handle stress and look after your mental health

Stress

Stress is a controversial term but is broadly understood to result from an “imbalance between demands and resources” or occurring when “pressure exceeds one’s perceived ability to cope.”6 Although stress is not unique to medicine, commentators have suggested that the following combination of factors may contribute to stress in doctors: excessive workload7; dealing with patients’ suffering and one’s own mistakes or fear of them; and lack of professional support and training, particularly in the areas of communication, leadership, and management.

These factors contribute to a subjective sense of overload and inability to cope, which may then be compounded by maladaptive responses such as working long hours or drinking heavily.8 A longitudinal study of 1668 UK doctors found that perceived high workload and lack of support correlate with stress and burnout reported five or six years earlier, when the doctors were preregistration house officers carrying out entirely different jobs. The study also found that doctors with greater stress and emotional exhaustion had higher neuroticism scores.9

Why does stress matter?

Stress matters because a proportion of doctors experiencing prolonged job stress will develop a more serious problem such as burnout (defined as emotional exhaustion, depersonalisation, and decreased sense of personal accomplishment owing to work stress), depression, an anxiety disorder, and/or drug or alcohol dependence.10 The risk may be particularly acute for women doctors, in whom psychiatric morbidity is more common than in male doctors and suicide is twice as common as in women in the general population.11

Stress matters for patients too. A postal survey of 1794 UK NHS hospital consultants found that those with poor mental health were more likely to report that they gave reduced standards of care to patients by, for example, taking short cuts.12 A third of 225 doctors in another survey reported incidents where they believed that symptoms of stress had negatively affected patient care.13 These findings might indicate that stressed doctors are more likely to be self critical and thus report errors. However, more objective studies suggest that reducing stress for doctors is good for patients. A case-control study found that the introduction of stress management courses to 22 hospitals was associated with a substantial reduction in the rate of malpractice claims compared with the control hospitals.14

How to prevent stress from affecting your mental health

Prevention of stress related illness is currently the subject of a vast amount of empirical research. A recent systematic review of the literature on interventions to prevent burnout in junior doctors concluded that few of the existing studies undertaken were of sufficient methodological quality to be included.15 However, two interventions that used meditation-type practice did seem to improve mood disturbance in both junior doctors and medical students.16 17

A postal questionnaire sent to 2456 UK doctors working in their first year showed that these doctors found that talking through their problems, either with a colleague or with someone outside medicine, was a helpful coping strategy.7 The responses indicated that these doctors’ workload often made it difficult for them to find the time for such discussions; formal mentoring schemes separate from appraisal and embedded in training rotations may therefore help.

Box 1 outlines key steps that doctors can take as individuals for preventing stress, and suggestions for organisations, educators, and leaders.

How to recognise when job stress has affected your or a colleague’s mental health

The General Medical Council advises that doctors should be “alive to mental health problems, depression, and alcohol and drug dependence [in colleagues]” and should “Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.”25

It is sometimes difficult to distinguish job stress from a more serious mental health problem. Box 2 gives some “red flag” symptoms that alert you to the possibility that you or a colleague may need further support or advice. If in doubt, the priority is to seek appropriate assessment for you or help a colleague to do the same.

How to access services for yourself or a colleague

An overview of sources of help for doctors is outlined in box 3. Doctors need to be aware that most sources of help operate entirely confidentially and separately from internal bodies (such as trusts) or external agencies (such as the GMC) and that it is only necessary to breach this confidentiality in exceptional circumstances.

How to best help and support an unwell colleague is a complex matter, and little empirical evidence currently exists to guide doctors about the best way to proceed. An appropriate response will depend on the nature of your colleague’s apparent difficulty. If you think a colleague is stressed or may have depression, perhaps start by talking about your concerns gently but directly with him or her and then try to facilitate an assessment (by directing your colleague to a source of help).

If you believe that a colleague’s poor mental health may be influencing his or her ability to practise as a doctor, you will require more expert guidance about the best way to proceed. Your local hospital authority may have existing procedures that can offer you support and advice; hospital trusts’ guidelines vary but most would encourage you to share your concerns with a supervisor, trainer, or trusted colleague first. The medical defence organisations or the BMA’s “Doctors for Doctors” service also offer anonymous advice in such situations.

How to get well

All doctors should be registered with a general practitioner, who should be your first point of contact if you have any concerns about your health. Depending on the problem, various interventions are available. For depression, antidepressants and talking treatments based on cognitive behavioural therapy have the best evidence base currently.27 Other types of talking treatment, such as interpersonal or psychodynamic psychotherapy, are also effective.28 29 For more information about these treatment options see the Royal College of Psychiatrists’ website (www.rcpsych.ac.uk/mentalhealthinfo/treatments.aspx), and for an accredited UK therapist in your area you can search on www.bacp.co.uk (for psychodynamic or interpersonal therapists) or www.cbtregisteruk.com (for cognitive behavioural therapists).

General practitioners can often recommend local therapists, and the new initiative Increased Access to Psychological Therapies will mean that cognitive behavioural therapy will become more widely available in primary care in England in the coming years. Other approaches that may be useful for depression include mindfulness,19 and exercise.30

How the system can help

High quality services providing confidential counselling, coaching, psychotherapy, and treatment for alcohol and drug problems need to be visible and promptly available to doctors throughout their training.23 Additionally, doctors should be able to access consultations, and admission if necessary, outside their area of work. The establishment of the new Practitioner Health Programme pilot in London is an innovative service model that is likely to appeal to doctors as patients (box 3).

What are the challenges?